Rheumatology Advance Access originally published online on January 23, 2007
Rheumatology 2007 46(4):715-716; doi:10.1093/rheumatology/kel410
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LETTERS TO THE EDITOR |
Uptake of influenza vaccination in patients on immunosuppressant agents for rheumatological diseases: a follow-up audit of the influence of secondary care
Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, UK
Correspondence to: S. Pathare, E-mail: skp1110{at}hotmail.com
SIR, patients with rheumatological diseases such as rheumatoid arthritis (RA) are at increased risk of infections and treatment with immunosuppressive agents may increase this risk [1]. Guidelines from the British Society for Rheumatology (BSR) state that patients with RA on immunosuppressant disease-modifying anti-rheumatic drugs (DMARDs) should receive annual Influenza immunization [2]. An overall target set by the Department of Health (DoH) in UK is 70% for the uptake of Influenza immunization in people aged 65 yrs [3]. An audit performed at the Queen Elizabeth Hospital in Gateshead in 2002 following publication of these guidelines showed that the uptake of Influenza immunization in patients with RA on methotrexate (MTX) was suboptimal (56%), particularly in those <65 yrs of age. The commonest reason for this was the fact that they had not been offered the vaccine [4]. Following the audit the measures taken to increase immunization awareness amongst patients included:
- Discussion of immunization status during new patient education and clinic visits.
- Provision of DoH publication ‘Fighting with Flu’ [3].
- A list of patients on DMARDs was issued to each GP practice advising Influenza immunization as per BSR guidelines prior to the annual immunization campaign.
The study was repeated in 2004 to determine whether these measures had been successful and further to determine the uptake of pneumococcal immunization.
Patients attending rheumatology clinics who were known to be on DMARDs or corticosteroids in autumn of 2003 were questioned using a standardized questionnaire about the uptake of Influenza and pneumococcal immunization. A total of 169 questionnaires were completed, in which 158 (93%) patients were on DMARDs, 69% of these were females and 48% were above the age of 65 yrs. MTX was the most common DMARD (65% of patients). Influenza immunization was offered to 85% of the patients in 2003. Of these, 79% (67% of total) accepted the vaccine. Most (81%) were offered immunization by primary care, while 15% of patients recalled a recommendation for immunization against Influenza by the hospital (10% in 2002).
The majority of patients (83%) had RA. Fifty-nine (80%) of the 73 patients aged >65 yrs who were offered Influenza immunization they accepted it, compared with an uptake of 85% for those aged <65 yrs (Table 1). In patients with RA, 123 (87%) were offered Influenza immunization and of those 98 (79%) accepted. The uptake of Influenza immunization was 72% in patients with RA on MTX in 2003 as compared with 56% in 2002 (P = 0.036).
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The number of patients who had pneumococcal vaccine was low (34%) but only 39% recalled being offered immunization. Patients over the age of 65 were more likely to have received the pneumococcal immunization regardless of the DMARD (overall 49 vs 24%) as compared with those under the age of 65 yrs (P = 0.001, chi-square).
In the group of 30 patients who refused vaccination, 27% were still unsure of the need for immunization or felt too fit, 27% had a previous adverse reaction, 3% had heard bad reports, 3% had developed a flare of the disease with immunization received previously and 40% did not give any reason for declining immunization against Influenza.
Influenza immunization is highly effective in preventing morbidity and mortality in the elderly and those with chronic conditions [5]. Pneumococcal and Influenza immunization is advocated in most national immunization guidelines for such patient groups [6, 7].
The target for uptake of Influenza immunization among people aged 
65 yrs is 70% and it is recommended that uptake in the under 65 at risk group should also be brought up to this level [8, 9]. With increasing use of aggressive immunosuppression in rheumatology there is a need to increase awareness amongst medical professionals and patients about the requirement for Influenza and pneumococcal immunization. A recent Swedish study suggested that antibody response to pneumococcal immunization is impaired in patients receiving MTX but not in those on anti-TNFs alone or low-dose prednisolone leading the group to recommend that if possible immunization should occur prior to the initiation of MTX [10]. We feel that pneumovax should be considered for all patients with RA given this population's increased susceptibility to infection. We would also recommend that for those on treatment with immunosuppressive drugs pneumovax is repeated after 5 yrs especially for those on MTX for the reasons above [11].
In conclusion, simple interventions by the secondary care team can increase the uptake of Influenza vaccination as recommended by the DoH and BSR. Further work is needed to increase the public's understanding of the benefits of the vaccination and to alleviate their fears regarding its use. With regard to the pneumococcal immunization, rheumatologists should highlight the need for vaccination to both primary care providers and patients. Immunization should occur early in disease and revaccination should be considered at 5 yrs. Also financial incentives exist in primary care to encourage immunization of ‘at risk’ groups. These measures should decrease the risk of common respiratory infections in our vulnerable patient population.
The authors have declared no conflicts of interest.
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References |
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 Top References |
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- Gluck T. (2006) Vaccinate your immunocompromised patients!. Rheumatology 45:9–10.
[Free Full Text] - BSR National guidelines for the monitoring of second line drugs. (2000) (British Society for Rheumatology, London).
- Summary of Flu immunisation policy – Department of health. http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/Flu.
- Bridges MJ, Coady D, Kelly CA, et al. (2003) Factors influencing uptake of influenza vaccination in patients with rheumatoid arthritis. Ann Rheum Dis 62:685.
[Free Full Text] - Gross PA, Hermogenes AW, Sacks HS, Lau J, Levandowski M. (1995) The efficacy of influenza vaccine in elderly persons: a meta-analysis and review of literature. Ann Intern Med 123:518–27.
[Abstract/Free Full Text] - Centres for Disease Control and Prevention. (2004) Recommended adult immunisation schedule – United States, October 2004 – September 2005. MMWR 53:Q1–Q4 Available at http://www.cdc.gov/nip/recs/adult-schedule.htm.[Medline]
- STIKO. (2005) Hinweise zu Impfungen fur Patienten mit Immundefizienz. Epidemiol Bull 353–64 Available at http://www.rki.de.
- PL CMO. (2004) Update on the influenza and pneumococcal immunisation programmes 4: http://www.dh.gov.uk.
- SEHD/CMO. (2004) Influenza immunization programme for 2004–05. Pneumococcal immunization programme for 2004-5 15:.
- Kapetanovic MC, Saxne T, Sjoholm A, et al. (2006) Influence of methotrexate, TNF blockers and prednisolone on antibody responses to pneumococcal polysaccharide vaccine in patients with rheumatoid arthritis. Rheumatology 45:106–111.
[Abstract/Free Full Text] - British Society for rheumatology. (2002) Vaccinations in immunocompromised persons—guidelines for the patient taking immunosuppressants, steroids and the new biologic therapies. (British Society for Rheumatology, London) (www.rheumatology.org.uk).
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